MNU Health Assessment Book Final 2023-2024 PDF

Overview of a Holistic Health Assessment Health: As defined by World Health Organization it defined as a state of complete physical, mental & social Wellbeing, not merely the absence of disease. The new definition, considers health as a dynamic state of well-being with different levels of...

Overview of a Holistic Health Assessment Health: As defined by World Health Organization it defined as a state of complete physical, mental & social Wellbeing, not merely the absence of disease. The new definition, considers health as a dynamic state of well-being with different levels of functional abilities at different point in time. So a diabetic patient no doubt has a disease, but there are times when the client feels well and can be called healthy Health assessment: It is a dynamic and continuous process involving the collection, verification, and organization of information about a client within a specific healthcare context. Or it is a systematic method of collecting data about a patient. Purpose of the health assessment:  To establish a database about the client’s perceived needs, health problems, and responses to these problems.  To determine the patients' current and ongoing health status.  To predict risks to health.  To identify health promoting activities.  To provide an updated baseline for a healthy client Principles of health assessment An appropriate and timely assessment provides a better establishment of nursing care and intervention.  The health assessment process should include certain data collection, documentation, and evaluation of the patient's physical condition.  The documents should be objective, accurate, concise, specific, and most up-to-date.  This needs to be performed in all types of settings whenever the interaction between a client and a nurse occurs.  Gathered or collected pieces of information are needed to be discussed with professional caregivers and specialists. 11   Confidentiality is needed to be maintained. Types of assessment  Initial Comprehensive assessment: Also called an admission assessment, it is performed when client enter health care system. Involves collection of subjective data about the client's perception of health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client's overall function) as well as objective data gathered during a step-by-step physical examination.  Ongoing or Partial assessment: Consists of data collection that occurs after the comprehensive database is established. This consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on his health status. Any problems that were initially detected in the client's body system or holistic health patterns are reassessed in less depth to determine any major changes (deterioration or improvement) from the baseline data.  Focus or Problem Oriented assessment: It is performed when a comprehensive database exists for a client and he/she comes to the health care agency with a specific health concern. Consists of a thorough assessment of a particular client problem and does not cover areas not related to the problem. For example, if the client tells that he has ear pain, nurse would ask him questions about the pain, possible hearing loss, dizziness, ringing in his ears, and personal ear care. Sexual functioning & bowel habits would be unnecessary and inappropriate.  Emergency assessment: An emergency assessment is a very rapid assessment performed in life-threatening situations. In such situations (choking, cardiac arrest, drowning), an immediate diagnosis is needed to provide prompt treatment. 12  Components of health assessment: Health assessment Health history Physical examination History of present illness, Past, present medical history Inspection, Palpation, Family history Percussion, Auscultation Social history A comprehensive patient assessment harvests both subjective and objective findings.  Subjective findings are obtained from the health history and body systems review.  Objective findings are collected from the physical examination. The Interview: The interview, in which subjective data are gathered, includes the health history and focused interview. The data collected will come from primary and secondary sources. The primary source from which data are collected is the patient, and the patient is the direct source. An indirect or secondary source would include a significant other, family members, caregivers, other members of the health team, and medical records. Comparing subjective and objective data: Subjective Objective Description Data elicited and verified Data directly or indirectly by the client observed through measurement Sources Client Observations and physical Family and significant assessment findings of the nurse others or other health care professionals. Client record Documentation of assessments Other health care made in client record. professionals Observations made by the client's family or significant others. Methods used to Client interview Observation and physical 13 obtain data examination Skills needed to Interview and therapeutic Inspection obtain data communication skills Palpation Caring ability and empathy Percussion Listening skills Auscultation Examples "I have a headache." Respirations 16 per minute "It frightens me." BP 180/100, "I am not hungry." apical pulse 80 and irregular X-ray reveals fractured pelvis Interviewing and Communication Techniques: A. Health History Information about the patient's health in his or her own words and based on the patient's own perceptions. Includes biographic data, perceptions about health, past and present history of illness and injury, family history, a review of systems, and health. Skills needed for taking effective health history Communication Skills……. is the exchange of information between individuals. Interactional Skills….. are actions that are used during the encoding ‖ is the process of formulating a message for transmission to another person/decoding ―the process of searching through one's memory, experience, and knowledge base to determine the meaning of the intended message‖ process to obtain and disseminate information, develop relationships, and promote understanding of self and others. Listening….is paying undivided attention to what the patient says and does. Attending…. Giving full attention. to verbal and nonverbal messages Paraphrasing, Leading, Questioning, Reflecting and Summarizing The Health History ”Interview” The nurse uses the health history and interview in various healthcare settings to create a comprehensive account of the patient's past and present health. The nurse can use this database, which provides a total picture of the patient's past and present physical, psychological, social, cultural, and spiritual health, to formulate nursing diagnoses and plan the patient's care. 14 Preparing the Client: Health examinations are usually painless; however, it is important to determine in advance any positions that are contraindicated for a particular client. The nurse assists the client as needed to undress and put on a gown. Clients should empty their bladders before the examination. Doing so helps them feel more relaxed and facilitates palpation of the abdomen and pubic area. If a urinalysis is required, the urine should be collected in a container for that purpose. Preparing the Environment Providing privacy is important The time for the physical assessment should be convenient to both the client and the nurse. The environment needs to be well lighted, and the equipment should be organized for efficient use. A client who is physically relaxed will usually experience little discomfort. The room should be warm enough to be comfortable for the client. Positioning Several positions are frequently required during the physical assessment. It is important to consider the client’s ability to assume a position. The client’s physical condition, energy level, and age should also be taken into consideration. Draping Drapes should be arranged so that the area to be assessed is exposed and other body areas are covered. Exposure of the body is frequently embarrassing to clients. Drapes provide not only a degree of privacy but also warmth. 15  Drapes are made of paper, cloth, or bed linen. Instrumentation All equipment required for the health assessment should be clean, in good working order, and readily accessible. Equipment is frequently set up on trays, ready for use. B. Physical Assessment: The physical examination can be general or particular due to a specific problem. It can be frequent if serious health issues are involved. It is performed head to toe and generally lasts for 25-30 minutes. It measures vital signs like body temperature, blood pressure, breathing rate, oxygen pressure, and heart rate. The evaluation process goes through some particular stages. It includes four techniques: Inspection, palpation, percussion, and auscultation. Use these techniques in this sequence except when perform an abdominal assessment. Because palpation and percussion can alter bowel sounds, the sequence for assessing the abdomen is inspection, auscultation, percussion, and palpation. Basic techniques of physical assessment Inspection: It is the skill of observing the patient in a deliberate, systematic manner. It begins the moment the nurse meets the patient and continues until the end of the patient-nurse interaction. Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations. Observe for color, size, location, movement, texture, symmetry, odors, drainage and sounds as assess each body system. Inspection begins with a survey of the patient’s appearance and a comparison of the right and left sides of the patient's body, which should be nearly symmetric. As the nurse assesses each body system or region, he or she inspects for color, size, shape, or region, he or she inspects for color, size, shape, contour, symmetry, movement, or drainage. When inspecting a large body region, the nurse should proceed from general overview to specific detail. 16  For example, when inspecting the leg, the nurse surveys the entire leg first and then focuses on each part, including the thigh, knee, calf, ankle, foot, and toes in succession. Although the nurse will perform most of the inspection without the help of instruments, some special tools for visualizing certain body organs or regions are important. For example, the ophthalmoscope is used to inspect the inner aspect of the eye. Palpation: Palpation requires touching the patient with different parts of hands, using varying degrees of pressure. Because hands are the nurse tools, keep the fingernails short and hands warm. Wear gloves when palpating mucous membranes or areas in contact with body fluids. Palpate tender areas last. Percussion: Percussion involves tapping fingers or hands quickly and sharply against parts of the patient’s body to locate organ borders, identifies organ shape and position, and determines if an organ is solid or filled with fluid or gas. 17 Types of palpation Light palpation Use this technique to feel for surface abnormalities. Depress the skin 1/2 to 3/4 (1.5 to 2 cm) with finger pads, using the lightest touch possible. Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. Deep palpation Use this technique to feel internal organs and masses for size, shape, tenderness, symmetry, and mobility. Depress the skin 11/2 to 2 (4 to 5 cm) with firm, deep pressure. Use one hand on top of the other to exert firmer pressure, if needed. 18 Types of percussion: Direct percussion This technique reveals tenderness; It’s commonly used to assess an adult patient’s sinuses. Here’s how to do it: Using one or two fingers, tap directly on the body part. Ask the patient to tell which areas are painful and watch his face for signs of discomfort. Indirect percussion: This technique elicits sounds that give clues to the makeup of the underlying tissue. Press the distal part of the middle finger of non-dominant hand firmly on the body part. Keep the rest of the hand off in the body surface. Flex the wrist of the dominant hand. Using the middle finger of the dominant hand, tap quickly and directly over the point where the other middle finger touches the patient’s skin. Listen to the sounds produced Auscultation: Auscultation involves listening for various breaths, heart, and bowel sounds with a stethoscope. Provide a quiet environment. Make sure the area to be auscultated is exposed (Auscultating over a gown or bed linens can interfere with sounds) 19  Warm the stethoscope head in hand. Close eyes to help focus the attention.  How to auscultate use the diaphragm to pick up high-pitched sounds, such as first (S1) and second (S2) heart sounds. Hold the diaphragm firmly against the patient’s skin, enough to leave a slight ring on the skin afterward.  Use the bell to pick up low-pitched sounds, such as third (S3) and fourth (S4) heart sounds. Hold the bell lightly against the patient’s skin, just enough to form a seal. Holding the bell too firmly causes the skin to act as a diaphragm, obliterating low- pitched sounds.  Listen to and try to identify the characteristics of one sound at a time. 21